gestational diabetes
Introduction
Introduction to Pregnancy with Diabetes Gestational diabetes mellitus (GDM) refers to the occurrence of pregnancy-related pregnancy on the basis of the original diabetes, or recessive diabetes before pregnancy, and development of diabetes after pregnancy. It is a high-risk pregnancy and is harmful to both mother and child. Since the application of insulin to the clinic, the mortality rate of pregnant women and their neonates has been significantly reduced. However, the clinical process of maternal diabetes is complicated, and the maternal and infant mortality rate is still high, and it must be paid enough attention. basic knowledge Sickness ratio: 0.05% Susceptible population: pregnant women Mode of infection: non-infectious Complications: diabetic ketoacidosis acute myocardial infarction diarrhea coma
Cause
Pregnancy with diabetes etiology
Age factor (30%):
Older pregnancies are recognized as a major risk factor for gestational diabetes. The risk of developing gestational diabetes in pregnant women aged 40 years and older is 8.2 times that of pregnant women aged 20 to 30. In addition to affecting the occurrence of gestational diabetes, the older the age, the smaller the gestational age of pregnant women diagnosed with gestational diabetes. Among pregnant women who can diagnose gestational diabetes before 24 weeks of gestation, pregnant women aged 30 and over account for 63.7%. Only 45.2% were diagnosed after 24 weeks.
Obesity (25%):
Obesity is an important risk factor for impaired glucose tolerance and diabetes, and is no exception for gestational diabetes. Other environmental factors such as age, economy, cultural level and diet structure are synergistic with obesity.
Race (10%):
The relationship with race, gestational diabetes has obvious regional and ethnic relevance, compared with the prevalence of gestational diabetes in white European women, the Indian subcontinent Asia, Arabia and black are 11 times, 8 times, 6 times the former And 6 times. Apart from genetic factors, racial factors cannot exclude the role of economic culture, eating habits and other factors.
Family history of diabetes (25%):
Family history of diabetes and history of adverse obstetrics are risk factors for gestational diabetes. The risk of gestational diabetes in family history of diabetes is 1.55 times higher than that of family history without diabetes, and the family history of diabetes in first-degree relatives is 2.89 times higher. The knowledge related to the causes of gestational diabetes is briefly introduced here, and I hope to help everyone. Gestational diabetes can have a great impact on both the mother and the fetus. It is hoped that pregnant women will pay more attention to their own bodies. If they suffer from this disease, they must go to a regular hospital for treatment in time to avoid delaying the condition.
Normal human oral glucose caused an increase in blood insulin levels, fasting insulin levels were lower than 179pmol / L (25U / ml), 30 minutes after oral glucose, rose to a peak, about 359pmol / L (50U / ml), and then gradually decline After returning to the fasting level after 2 hours, ketosis type diabetes is caused by lack of insulin in the circulation, and does not respond after oral administration of glucose; however, mild obese diabetes has a delayed response, and insulin can rise to an abnormally high level, indicating that patients with mild diabetes Islet cells have a slow but excessive response.
Sensitivity of gestational diabetes: After oral glucose in early pregnancy, insulin levels in fasting and peaking are similar to non-pregnancy, but insulin levels in fasting and peaks in late pregnancy are higher than those in non-pregnancy, combined with post-pregnancy meals. The tendency to hyperglycemia clearly shows that the sensitivity of insulin decreases in the third trimester, so women must produce and secrete more insulin during pregnancy to maintain normal glucose homeostasis. Most women have adequate pancreatic beta-cell reserves. While a small number of people become diabetic, and women with diabetes have decreased sensitivity to insulin, it means that exogenous insulin sometimes needs to increase by two to three times as pregnancy progresses.
The cause of changes in insulin sensitivity during pregnancy is not known, but may be caused by several factors, including placental insulin degradation, circulating free cortisol, elevated estrogen and progesterone levels, and placental lactogen (HPL). The result of antagonism of insulin.
During pregnancy, along with the growth of the fetal placenta, insulin antagonism occurs on the one hand, and insulin hyperplasia occurs on the other hand, and disappears immediately after delivery, all of which indicate pancreatic activity during pregnancy and placental hormones (eg HPL, estrogen and progesterone levels are related to elevated levels. HPL, also known as human chorionic growth hormone, is very similar to growth hormone in immunology and biology. In normal pregnant women, HPL secretion rate and fetal placenta The growth curves are parallel, but do not shift with changes in glucose in the blood circulation. HPL has been shown to have both insulin-promoting and anti-insulin properties, but HPL primarily acts as an anti-insulin.
In pregnancy, in addition to the insulinotropic and anti-insulin effects of HPL, placental estrogen and progesterone are also involved in the regulation of glucose-insulin homeostasis, observed in human and animal experiments, after estradiol and progesterone production Excessive insulin secretion and islet hypertrophy, but the effect of glucose on the two is quite different. After the administration of estradiol, the response of insulin to glucose is obviously enhanced and the blood glucose level is decreased, but the progesterone is sensitive to insulin hypoglycemic effect. Sexual decline, although progesterone can cause insulin to multiply, but can not cause changes in glucose levels, these materials indicate that both estrogen and progesterone can cause insulin secretion, and progesterone has insulin antagonism.
Prevention
Pregnancy with diabetes prevention
1. The blood pressure, liver and kidney function, retinopathy and fetal health of pregnant women with diabetes should be closely monitored. It is best to start before pregnancy.
2. Effective control of diabetes before pregnancy, because the most serious malformation of the fetus occurs within 6-7 weeks of early pregnancy.
3. To avoid the occurrence of ketosis, the staple food should eat 300-400 grams per day, eat 5-6 times, a small amount of meals and multiple injections of insulin.
4. Gestational diabetes should be checked for blood sugar, and the amount of insulin should be increased or decreased in time.
5. Pregnant women with diabetes after pregnancy, early treatment.
6. Closely monitor the size and presence of the fetus.
Complication
Pregnancy with diabetes complications Complications diabetic ketoacidosis acute myocardial infarction diarrhea coma
Diabetic ketoacidosis coma is an acute complication of diabetes. When diabetic patients encounter acute stress, such as various infections, acute myocardial infarction, cerebrovascular accidents, etc., the metabolism of glucose metabolism is aggravated, fat decomposition is accelerated, and urine ketone body is positive. Known as diabetic ketosis, when the ketone body further accumulates, the protein decomposes, and the acidic metabolite increases, the blood pH decreases, resulting in acidosis, called diabetic ketoacidosis.
Diabetic hyperosmolar coma diabetes has not been diagnosed and treated in time to develop hyperosmolar coma, in addition to oral thiazide diuretics, glucocorticoids, hyperthyroidism, severe burns, high concentration of glucose treatment caused excessive water loss, high blood sugar, A variety of severe vomiting, diarrhea and other diseases caused by severe water loss can also cause hyperosmolar coma in diabetes.
Diabetes lactic acidosis lactic acid is an intermediate metabolite of glucose. The catabolism of glucose includes aerobic oxidation of glucose and anaerobic glycolysis of glucose. The former is the complete oxidation of glucose to carbon dioxide and water under normal aerobic conditions. It is the body. The main route of sugar decomposition capacity, most tissues can get enough oxygen for aerobic oxidation and rarely anaerobic glycolysis; the latter is the decomposition of glucose into lactic acid under anaerobic conditions.
Insulin hypoglycemia coma: more common in type I of the diabetes type II, fragile or type II, heavy, usually due to excessive insulin dose, especially when pregnant women with diabetes are vomiting, diarrhea, or too little diet, and postpartum.
Symptom
Pregnancy with diabetes symptoms Common symptoms Increased blood sugar levels Diabetes polydipsia Multi-urinary acidosis Poisoning pregnancy High blood flow coma pruritus Candida infection
The importance of early diagnosis
After the organ is fully differentiated, it will no longer be deformed. Infants with diabetes pregnancy often have congenital malformations before the 7th week of embryonic development, so early diagnosis and early treatment are very important.
Clinical manifestation
Pregnant women with diabetes can have a sudden increase in body weight during pregnancy, which is obviously obese, or symptoms of more than three (more food, more drink, more urine and weight loss); genital itching, vaginal and vulvar candida infection; In severe cases, ketoacidosis can occur with coma and even life-threatening.
Examine
Pregnancy with diabetes check
Laboratory inspection
(1) Determination of urine sugar: All pregnant women should be tested for urine sugar. If they are negative in early pregnancy, they should be repeated in the middle and late stages. During normal pregnancy, especially after 4 months of pregnancy, the renal tubules of pregnant women are glucose. The resorption capacity is reduced, sometimes the blood sugar level is within the normal range, but the diabetes is caused by the decline of the renal sugar threshold. In the postpartum lactation, physiological lactoseuria may occur, so the urine glucose positive person needs to be further fasted. Blood glucose and glucose tolerance were measured to confirm the diagnosis.
(2) Blood glucose measurement: The blood glucose level of normal pregnant women is generally lower than the normal value, rarely exceeds 5.6mmol/L (100mg/dl), and the fasting blood glucose is usually 3.34.4mmol/L (6080mg/dl).
(3) Determination of hemoglobin A1 (HbA1): blood glucose, glycated serum protein and glycated HbA1, all of which can be used as indicators to reflect the degree of diabetes control, but their significance is not the same, blood glucose concentration reflects the blood glucose level at the time of blood collection; glycated serum The protein reflects the average (total) level of blood glucose 1 to 2 weeks before blood collection; glycated HbA1 and HbA1c reflect the average (total) level of blood glucose within 8 to 12 weeks before blood collection, and hemoglobin slow glycosylation produces HbA1 during the red blood cell life cycle The amount of change in HbA is based on the average blood glucose level. The level of HbA1 in non-diabetics is about 4%, and that in diabetic patients can be as high as 20%. However, after treatment control, blood glucose levels can be reduced. HBA1 can be further divided into HBA1a and HbA1b. HbA1c and HbA1c account for the largest proportion. HBA1c can replace HBA1 level. The average HBA1 level in normal pregnancy is 6%, but it can be increased in diabetic pregnancy. As pregnancy progresses, diabetes can be reduced when control is better, so HbA1 determination is used. As an auxiliary method for blood glucose determination, Miller (1982) reported an increase in HBA1c, and the incidence of congenital malformations in pregnant women with diabetes was significantly higher. Description poorly controlled diabetes.
Diagnosis
Diagnosis and diagnosis of pregnancy complicated with diabetes
Need to be differentiated from physiological glucosuria during pregnancy, the incidence rate is 10% to 20%, due to temporary renal threshold reduction and diabetes, but normal blood glucose, suspicious determination of fasting blood glucose and glucose tolerance test.
Medical history and physical examination
Although important, it may be negative, so you should be aware of the possibility of diabetes if you have any of the following conditions.
(1) Family history of diabetes: The more people with diabetes in family members with pedigree, the more likely they are to have the disease.
(2) In the past, women have repeated abortions, unexplained stillbirth or stillbirth history, neonatal death, giant children, polyhydramnios or fetal malformations, etc., have a certain relationship with the existence of diabetes, urine sugar for these patients, Blood glucose and glucose tolerance are measured to determine the diagnosis in a timely manner.
Diabetes diagnostic criteria
(1) World Health Organization Diabetes Diagnostic Criteria (1980)
1) Diabetes diagnostic criteria (venous plasma true sugar): 1 has diabetes symptoms, no need for oral glucose tolerance (75g) test (OGTT), blood glucose at any time during the day >11.1mmol / L (200mg / dl) Or fasting blood glucose > 7.8mmol / L (140mg / dl); 2 with or without symptoms of diabetes, fasting blood glucose not only > 7.8mmol / L (140mg / dl); 3 symptoms of diabetes, and blood glucose did not meet the above diagnostic criteria, After oral administration of 75g of glucose after an empty stomach, blood glucose 11.1mmol/L (200mg/dl) for 2 hours; 4 OGTT for patients without diabetes, blood glucose 11.1mmol/L (200mg/dl) for 2 hours, and 1 hour Also 11.1mmol / L (200mg / dl), or repeat OGTT, 2 hours 11.1mmol / L (200mg / dl), or fasting 7.8mmol / L (140mg / dl).
2) Diagnostic criteria for impaired glucose tolerance: fasting blood glucose <7.8mmol/L (140mg/dl), OGTT 2-hour blood glucose >7.8mmol/L (140mg/dl), but <11.1mmol/L (200mg/dl), impaired glucose tolerance About 10% of patients can develop diabetes after 10 years, and they have a higher chance of coronary heart disease than normal people. They should be followed up regularly. Pregnant women can take the above diagnostic criteria, but those with low glucose tolerance should be treated according to diabetes.
(2) Diagnostic criteria for domestic diabetes: The recommendations of the Diabetes Research Collaboration Group at the 1982 enlarged meeting on diabetes diagnostic criteria are shown in Table 1.
Table 1 Diagnostic criteria for diabetes after oral glucose (100g) tolerance test
Time (h) | O | 0.5 | 1 | 2 | 3 |
Intravenous plasma sugar (mmol/L) | 6.9 | 11.1 | 10.5 | 8.3 | 6.9 |
(mg/dl) | 125 | 200 | 190 | 150 | 125 |
Description: 1 There are typical diabetes symptoms or complications such as diabetic ketoacidosis, fasting blood glucose > 7.2mmol / L (130mg / dl) and / or 2 hours after meals > 8.9mmol / L (160mg / dl), no need OGTT can be diagnosed as diabetes, 20.5 hours or 1 hour blood glucose value is selected as the highest point, and other time limit blood glucose values are 1 point, 4 points in total, 3 points out of 34 points the above various phase standards The diagnosis was diabetes. In the 4OGTT, the blood glucose level exceeded the upper limit of the normal mean and did not reach the diagnostic criteria, which was called abnormal glucose tolerance. The 5 blood glucose was measured by O-toluidine boric (TB method).
